Underprescribing of cardioprotective novel antidiabetic drugs in marginalized patients with type II diabetes mellitus

Abstract

Abstract Background Cardiovascular disease is the most common cause of increased mortality in patients with type 2 diabetes mellitus (T2DM). Novel antidiabetic agents such as sodium-glucose co-transporter 2 (SGLT-2) inhibitors and glucagon-like peptide 1 (GLP-1) agonists were shown to reduce this risk. SGLT-2 inhibitors are considered a secondary treatment option in patients with heart failure with reduced ejection fraction (HFrEF) in patients with or without T2DM. In patients with T2DM, these medications not only reduce hyperglycemia but also reduce the progression of chronic kidney disease (CKD). GLP-1 agonists are indicated for treatment of not only T2DM, but also obesity, and were shown to improve left ventricular ejection fraction, myocardial contractility, and endothelial function. The literature suggests that there may be disparities in prescribing patterns in marginalized populations. Objective The purpose of this study was to conduct a retrospective chart review to assess the adherence to the new guidelines regarding the use of SGLT2 inhibitors and GLP-1 agonists in marginalized patients with T2DM. Methods The study was conducted at a resident-run clinic that serves a large number of under-resourced individuals. Inclusion criteria included patients between the ages of 18 and 75 with T2DM seen in the clinic within 18 months prior to the start of the study with an A1c greater than 9.0. Exclusion criteria included patients with type 1 diabetes mellitus and patients with T2DM under care of endocrinology. We performed retrospective chart review to determine providers’ prescription practices. We created electronic patient database for this study. Results The data showed that 26.87% (n= 381) of the clinic’s population had an A1c greater than 9.0, of those 343 patients met the inclusion criteria. About 7.87% (27/343) of patients were identified with HFrEF. Of those, only 40.74% (11/27) were found to be on an SGLT2 inhibitor. Patients with CKD constituted 17.49% (60/343) of patients, and only 16.67% (10/60) of those were on an SGLT2 inhibitor. We identified 27.70% (95/343) of patients with a BMI between 30-35, and 30.32% (104/343) with a BMI greater than 35, but only 56.84% and 64.42% of those, respectively, were on a GLP-1 agonist. The patients that were not on the cardioprotective agents were 50.19% (135/269), 11.15% (9/269), and 12.64% (34/269) African American, Hispanic, and Asian American, respectively. Conclusions This study demonstrates that SGLT2 inhibitors and GLP-1 agonists are underprescribed in marginalized patients diagnosed with T2DM, even in those with the additional indication of heart failure and CKD. Most of those patients are of racial minorities. There are a number of barriers that could be contributing to the poor adherence to the guidelines in this population. Our next step is to analyze those barriers and develop a quality improvement project that would improve guideline-directed therapy for this under-resourced population.